An international comparison of noncommunicable disease reporting: the case of diabetes mellitus

Against the background of the growing burden associated with diabetes mellitus, the German Federal Ministry of Health commissioned the Robert Koch Institute to develop a national diabetes surveillance. The periodic publication of up-to-date data needed by diverse target audiences (dissemination) to develop subsequent public health measures is a crucial aspect of disease surveillance. The study produced an overview of diabetes surveillance in various countries with the intention of developing a dissemination strategy. This involved a two-stage process beginning with an online survey of public health experts from 46 countries. Structured Internet research was then carried out for countries that did not provide a response (19 out of 46). The majority of countries (38 out of 46; 83%) include diabetes in their health reporting; three quarters (29 out of 38; 77%) of these countries rely on an indicator-based reporting system. The study found that the most common formats used to publish information about diabetes and other noncommunicable diseases were topic-specific reports (24 out of 36; 67%) and national health reports (23 out of 36; 64%), followed by online formats such as websites or databases (20 out of 36; 57%). Moreover, health reporting primarily targets politicians (19 out of 20; 95%) as well as the media and the press (16 out of 20; 80%). The study found that both printed and online publications form part of a comprehensive dissemination strategy, however address different audiences.


Introduction
The burden associated with diabetes mellitus and other noncommunicable diseases (NCDs) is steadily increasing in Germany as it is throughout the world [1,2]. In 2013, the World Health Organization (WHO) adopted the Global Action Plan for the Prevention and Control of NCDs as a means of facing up to the growing challenges posed by noncommunicable diseases [3]. The WHO's action plan contains six objectives, one of which includes monitoring be used to provide NCD-related information, nor does it provide guidance on which information should be provided to the various target audiences. When it comes to formats and communication channels, however, advances in digitisation, in particular, are opening up new ways of visualising and processing data [13]. Moreover, social media and social networks offer further opportunities with which to disseminate health-related information [10,14].
In addition to building on the experience gained by other public health institutes, best practice examples from other countries are to be used as a model to develop a dissemination strategy for diabetes surveillance at the RKI. An international workshop was held in this context at the RKI in June 2018 that also involved the presentation of innovative formats [15]. Furthermore, a study of health reporting on NCDs was performed using diabetes as an example. The aim of the study was to provide an overview of formats and target audiences of health reporting by the member states of the Organisation for Economic Co-operation and Development (OECD), the European Union (EU), and other selected European countries.

Methodology
The study used a two-step approach to collect data about national health reporting of diabetes and noncommunicable diseases (Figure 1). The first step involved surveying national public health experts from the selected countries using an online survey in English. The survey focused on diabetes and NCD-specific health reporting including the formats that were being used and the target audience that was being addressed. The results were supplemented by health-related data that is needed for the implementation of public health measures aimed at protecting and promoting the health of the population ('data for action') [5]. This definition implies that health monitoring data should be processed in a manner that reflects the needs of its various target audiences. Data from health surveillance can be used to (1) identify high-risk populations, (2) develop prevention strategies, (3) draw up new hypotheses on diseases dynamics, (4) raise awareness about trends and disease-related risk factors, and (5) encourage people to take conscious decisions about their health [6,7].
In order for health reporting data to be used in this manner, target audiences must be provided with up-to-date information (dissemination). In public health sciences, as in other fields, a gap exists between the production of new knowledge and its translation into practice and policy [8]. This underscores the importance of developing a dissemination strategy as part of the surveillance system that can provide the basis for the development of informed health policy measures [9]. However, it is essential that formats and the communication channels used to disseminate the information reflect the competences and level of expertise that a specific target audience has with regard to a particular aim [10,11].
The WHO identifies four target audiences as part of its Global Monitoring Framework for the surveillance of noncommunicable diseases: (1) healthcare providers, (2) policy makers, (3) service providers, and (4) the general population [12]. In addition, other groups that also need to be addressed include patients, doctors who treat diabetics, and scientists and scientific institutions. The WHO does not state which formats or communication channels should 83% of countries include diabetes in their national health reporting.
reporting sought to address. Furthermore, respondents were also asked to upload the reports they mentioned during the questionnaire or to provide a link to documents that were available online. After the online survey had been completed, a review was undertaken to ensure that each country had only provided one response. If more than one survey existed for a country, the data provided on these questionnaires were merged.

Structured Internet research
Between August and September 2018, structured Internet research was conducted into countries that had not supplied any data by the end of the online survey period (July 2018). The analysis focused on the country's framework, indicators, and the formats used for diabetes and NCD-specific health reporting. The Internet research was carried out in the following manner: first, a search was conducted of the websites of the respective national public health institutes, health ministries and statistical offices for keywords linked to diabetes and noncommunicable diseases. The Google search engine was then used to search for a combination of terms. In each case, the search term consisted of either diabetes, noncommunicable disease or NCD, alongside surveillance, monitoring, strategy, report, health reporting or indicators. Lastly, the respective country name (in English) was added to the search term. The study then examined the first 30 search results. Public health institutes, ministries of health or statistical institutes do not always provide relevant information in English, German or French. In these cases, their websites were translated into English using Google Translate and structured Internet research into countries that did not participate in the expert survey. Finally, examples of best practices from successful health reporting were also selected. The selection was based on a narrative analysis of the results of the online survey and Internet research.
The survey was limited to OECD and EU member states and other selected European countries; 46 countries were included in the study (Table 1).

Online survey
The online survey of public health experts took place between April and July 2018. The survey used a questionnaire created with the Acuity4 survey software (version 5.5.1.205) from Voxco®. In order to recruit suitable participants, the RKI's network was used to contact EU and OECD public health institutes as well as those from other European countries. The aim was to ensure that people with expertise in diabetes and health reporting participated in the study. In cases where it was impossible to find someone suitable to answer the questionnaire, a request to participate in the survey was sent to health ministries and national statistical offices. Other institutions were only contacted if they had been named by a member of one of these institutions.
The online survey comprised 39 questions and was divided into two subject areas (Annex Table 1). On the one hand, the questionnaire focused on the framework behind diabetes-specific health reporting, its integration into a diabetes strategy, and the indicators and data sources that were used. On the other hand, it also examined the formats that were being used and the target audiences that health Infobox 1: An international comparison of noncommunicable disease reporting: the case of diabetes mellitus carried out for the remaining 19 countries so that diabetes-specific health reporting could be evaluated for all 46 countries included in the study. the resulting translations were searched for the keywords mentioned above.
The research was limited to the framework (strategy, indicators, data sources) and formats (reports, websites, databases) used by the country for health reporting. Furthermore, only reports and formats published in or after 2000 were included in the study. Unfortunately, it was impossible to identify the reports' target audiences as the websites that published them provided no relevant information about this issue.

Results
Of the 46 countries included in the overall study, 27 (59%) participated in the online survey ( Figure 1). The majority of participants were from public health institutes (20 out of 27; 74%) and, albeit less frequently, from health ministries ( Figure 3. The ranking demonstrates that most countries use epidemiological indicators such as incidence, prevalence and mortality of diabetes as well as behavioural risk factors. Indicators covering quality of care, complications and comorbidities were reported less frequently. In 23 out of 28 countries (82%), the indicators relied on data sources that included regularly conducted national health surveys. Routine data, such as claims data from hospitals and medical practices, insurance data and data from other institutions, are included in diabetes health reporting in 19 out of 28 (68%) countries.
In addition to questions about the framework governing diabetes surveillance, the study focused on the formats used and the intended audience of diabetes-specific health reporting. The study found that different formats were being used to deliver the results ( Figure 4). These can be The first part of the study focused on the framework employed for diabetes health reporting and the indicators used to depict developments in the course of the disease. In total, four out of five countries include diabetes mellitus in their national health reporting ( Figure 2). Of these, over three quarters have defined a national diabetes strategy or action plan. In addition, half of the countries that conduct diabetes health reporting state that they follow the WHO's NCD Global Monitoring Framework [16]. However, no conclusions could be made about ten of the 38 (26%) countries. The majority of countries (29 out of 38; 77%) use an indicator-based system for reporting diabetes, with eight countries using a system exclusively for diabetes mellitus and 21 countries including diabetes in their surveillance of noncommunicable diseases.
The evaluation of the indicators determined by the study led to the identification of 142 different indicators or indicator clusters that are used in diabetes surveillance. These were divided into the following six areas: epidemiology, (12 out of 36; 33%) as well as scientific publications (7 out of 36; 19%) are used to a much lesser extent. In addition to traditional printed formats, results in 20 out of 36 (56%) countries are provided on a website or online database, with 9 out of 36 (25%) countries providing a database that enables the results to be queried directly. More than half of the websites and online databases included tools for interactive data visualisation. Furthermore, 7 out of 36 (19%) countries use other formats to publish results. These are mainly newer formats related to social media such as Twitter, Facebook or YouTube, but also include press releases. According to the respondents, these formats are primarily used to draw attention to the issue of diabetes and to raise awareness in society about this health problem.
divided into printed formats (including digital formats in print layouts such as Word and PDF) and formats that were only available online (web pages and databases). The study evaluated a total of 67 reports, 25 online formats and nine other formats from 36 countries. These were either provided as links, uploaded by the respondents, or were found during the Internet research. Due to the common ground covered by the reports and for reasons of clarity, health reports on diabetes mellitus (DM) and on noncommunicable diseases (NCD) were summarised as DM/NCD reports. Two thirds of countries (24 out of 36; 67%) publish their results in a specific report on diabetes or together with other noncommunicable diseases. Furthermore, results are often included in countries' interdisciplinary national health reports. Flyers and fact sheets  Topic-specific and general health reports (67%) are the most commonly used formats to publish information about diabetes.
a year (35 out of 67; 52%) or within two to five years (28 out of 67; 42%). The public health experts were also asked about the target audiences that diabetes-specific health reporting was seeking to address ( Figure 5). Almost all of the countries surveyed primarily target policy and decision-makers in the health sector, followed by the media and the press, and Reports, flyers, websites and online databases are generally made available in a country's own language. In about half of the cases (48 out of 92; 52%), they are also available in English. However, English is an official language in seven of these countries. Most formats (67 out of 92; 73%) are published or updated regularly. The majority of reports, websites and databases are updated once  Target audiences of diabetes-specific health reporting (n=20 countries) Source: An international comparison of noncommunicable disease reporting: the case of diabetes mellitus their intended audience ( Figure 6). However, since articles in scientific journals are primarily aimed at scientists, and the category 'other formats' contained a diverse range of formats, neither was included in the overall evaluation.
Health sector professionals had provided information about the target audiences of 54 reports, all of which were then used in the study. The analysis demonstrated that interdisciplinary national health reports primarily target healthcare policy and decision-makers (21 out of 22; 96%) and the media and the press (20 out of 22; 91%). However, researchers (16 out of 22; 73%) and the general population (13 out of 22; 59%) were addressed in more than half of these cases. A similar picture emerges for topic-specific scientists and the general population. Slightly more than half of the surveyed countries list doctors who treat diabetics as their target audience. Diabetes patients are specifically addressed by just one in four countries. These results are based entirely on the data gathered from the countries that participated in the online survey; no information was available about the audience targeted by the documents identified through Internet research. In total, 20 countries provided information about the audiences that their formats were seeking to address (seven countries provided no information about this at all). Different formats are used to address different audiences and, as such, they were evaluated with respect to 56% of countries use websites or online databases to provide information about diabetes. The study also sought to select examples of best practices from the formats identified by the online survey and the Internet research (Table 2). Ultimately, the study identified print and online publications from four countries that the authors view as having successfully implemented various aspects of health reporting.

Discussion
The online survey of public health experts and the Internet research enabled a structured overview of diabetes-specific health reporting in the EU and OECD countries to be developed. The majority of countries under study include diabetes mellitus in their national health reporting and have established indicators for disease surveillance. Health reports that were either printed or typeset and published online were the most commonly used formats. Online health reports on diabetes and noncommunicable diseases. Just under half of these reports target the media and the press. In contrast, flyers and fact sheets on diabetes were primarily aimed at the general population (4 out of 4) and, to a lesser extent, at political decision-makers and the media (3 out of 4). In addition, treating physicians as well as diabetes patients themselves are also named as target audiences in these cases (2 out of 4). Online formats (mainly websites) were aimed at the general population (9 out of 9) as well as the media and the press (7 out of 9). However, some online formats were also directed at diabetes patients (5 out of 9; 57%) and their physicians (5 out of 9).
This results in a clear picture: whereas political decision-makers are particularly targeted by interdisciplinary and topic-specific health reports, online formats, flyers and fact sheets are mainly used to address the general population. The media and the press, as the second most commonly mentioned target audiences, are addressed via both surveys and routine data to map the dynamics of the disease. Information about the strengths and weaknesses as well as the opportunities offered by these data sources can be found in this issue of the Journal of Health Monitoring in the contributions entitled Social inequality and diabetes mellitus and secondary data in diabetes surveillance. At the same time, the literature also provides very few recommendations or reviews of the formats and communication channels that are used for health reporting in the context of diabetes and other NCDs. As part of its framework, the WHO recommends the publication of fact sheets and data books (comprehensive volumes containing tables) that are entirely focused on the data [12] and that only take the requirements of target audiences with regard to format and data processing into account to a limited extent.
The study found that traditional printed reports are the most common publications used to provide information from disease surveillance. However, websites and online databases also offer a variety of options for data visualisation and are already being used by some countries to present the results from the surveillance of noncommunicable diseases. These tools are already being used to a greater extent in the surveillance of infectious diseases [18]. For example, the AIDSVu project uses regional analyses to identify vulnerable groups and subsequently implement targeted public health interventions in the most affected communities [19]. This approach could also open up diverse opportunities for NCD surveillance. For example, the Fingertips platform operated by Public Health England (Table 2) provides detailed analyses of various diabetes indicators that are used at the regional level to plan public formats such as websites and databases are used in more than half of the countries under study, some of which also provide innovative visualisation tools. All of the countries principally targeted policy makers, followed by the media and press, individuals and institutions involved in public health research, and the general population.
The literature provides very little information that could offer an overview of the surveillance systems used to collect data on noncommunicable diseases in various countries. However, as part of its action plan for the prevention and control of NCDs, the WHO regularly reports on the progress that each member state is making towards reaching the action plan's objectives, and also publishes relevant documents [17]. The proportion of countries with an identified diabetes strategy is comparable to the results of the online survey. The few exceptions that did occur were due to the fact that five cases from the online survey involved general NCD strategies that only implicitly included diabetes.
Although the WHO Framework [16] recommends that countries monitor behavioural risk factors (alcohol consumption, tobacco consumption, physical inactivity, obesity and overweight, unhealthy dietary habits) as part of their disease surveillance, the study found that only half of countries do so. However, closer analysis of the indicators demonstrates that two thirds of indicator systems include behavioural risk factors as indicators, and, thus, the majority of indicator systems do indeed reflect the WHO's approach. Moreover, the majority of countries also use data sources that contain both primary and secondary data. Diabetes surveillance at the RKI also includes behavioural risk factors among its indicators [4] as well as data from health politics; as of this time, the impact of the media is yet to have been unequivocally proven [21]. Moreover, personal contact, which can take place during individual meetings and symposia, is particularly important when it comes to addressing politicians [10]. In summary, it is crucial that the needs of different target audiences are considered [22,23] and that indicators are used to review the use of the formats provided [10, 24,25].

Limitations
The two-step approach and the use of two different methods to collect data on diabetes-specific health reporting means the study faces a number of limitations. As some countries did not participate in the online survey, the only information and documents available in these cases were those that were found on the Internet. These were available in English, German or French or via Google Translate. Moreover, as data about target audiences are not freely available and can only be supplied by public health experts, the Internet research was unable to provide information about the intended target audiences in these cases. Similarly, as no information was available about the people who were actually using the respective formats, it was impossible to judge whether the intended audiences were actually being reached. Furthermore, the study was limited to publications by state institutions and ministries; publications by non-governmental organisations, such as patient associations or professional associations, were not included in the analyses. Equally, the study's focus on national health reporting meant that regional reports or other regional formats were not considered. Finally, it is unclear health measures [15]. In addition, social media offer new opportunities to provide information to the public [10] and are already being used in some countries. In these cases, the focus is on raising awareness about diseases such as diabetes and their related risk factors. Similarly, the CDC (Centers for Disease Control and Prevention) in the United States of America have developed infographics that provide information about diabetes to the general public (Table 2). However, more research is needed into the effectiveness of public health interventions via social media [14].
The online survey found that diabetes reporting primarily seeks to address policymakers and health-care decision-makers, followed by the media and press. The WHO also identifies policymakers and health-care decision-makers as two of its four target audiences for information from NCD surveillance in addition to service providers and the general population [12]. The literature also emphasises the importance of addressing service providers and the general public during the establishment of public health surveillance systems [6,7,10]. Whereas diabetes surveillance tends to target politicians with the aim of encouraging the development of interventions and other public health measures (data-based decision-making) [20], the primary purpose of providing information to the general public is to raise awareness about diseases and risk factors as well as to provide other information that is relevant to public health [7]. The media and the press can serve as important disseminators of information aimed at the general public and, therefore, indirectly raise awareness among politicians of the importance of specific topics [9]. However, a discussion is currently taking place in the literature about the effectiveness of the media in terms of its impact on noncommunicable diseases. In order to address these audiences, a website is to be developed to provide visual representation of the results of diabetes surveillance; social media, such as Twitter and YouTube, are also to be used more regularly. The examples of best practices, which were collected during the survey and Internet research, will provide an important basis for the further development of these formats.
The German version of the article is available at: www.rki.de/journalhealthmonitoring whether the results of the study can be applied to all noncommunicable diseases, as diabetes receives greater attention than other diseases.

Conclusion and outlook
Public health surveillance systems provide the data required to make health policy decisions and to establish public health policies. The growing complexity caused by the increasing number of data sources and findings from scientific research means that information needs to be provided transparently and understandably. In addition to more traditional formats, such as reports, new tools for visualisation and interactive databases can enable data to be depicted in a manner that is understandable and which facilitates access to different target audiences.
Health reports about NCDs primarily address politicians and health policy decision-makers. However, these individuals can be reached in different ways. In addition to reports, established communication tools and social media also provide appropriate communication channels that can raise the priority and awareness of specific public health challenges. Discussions and symposia also constitute an important aspect of dissemination strategies.
The study's findings are to be used to develop a dissemination strategy for diabetes surveillance at the RKI. Diabetes surveillance particularly targets politicians and decision-makers in the healthcare sector. In line with the results of this study, a diabetes report is to be drawn up for this target audience. In addition, information is also to be provided to the general public and the media with the aim of raising awareness about the growing challenges posed by   Physiological and metabolic risk factors: raised blood pressure, overweight/obesity, raised blood glucose, and raised cholesterol.
Social determinants: educational level, household income, and access to health care.
Morbidity: Cancer incidence and type (as core).

Health system capacity and response
Interventions and health system capacity: infrastructure, policies and plans, access to key health-care interventions and treatments, and partnerships.

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